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Assessment Nursing Diagnosis Inference Objectives Nursing Intervention Rationale Evaluation
Assessment Nursing Diagnosis Inference Objectives Nursing Intervention Rationale Evaluation
DIAGNOSIS INTERVENTION
INDEPENDENT:
Subjective: Impaired gas Cancer is a class After 8 hours of Note respiratory rate, Respiration may be After 8 hours of
exchange related of diseases nursing depth, and ease of increased as a result of nursing intervention
“Nakakaranas ako
to altered characterized by intervention the respirations. Observe pain or as an initial the patient was able
ng hingal sa
oxygen supply. out-of-control patient will for the use of compensatory to demonstrate
paghinga at
cell growth, and demonstrate accessory muscles, mechanism to improved ventilation
panankit ng
lung cancer improved pursed lip breathing, accommodate for loss of and adequate
dibdib” (Lately,
occurs when this ventilation and changes in skin or lung tissue. Increased oxygenation of
I've been
uncontrolled cell adequate mucous membrane work of breathing and tissues by ABGs
experiencing
growth begins in oxygenation of color. cyanosis may indicate within patient’s
shortness of breath
one or both tissues by ABGs increasing oxygen normal range.
and chest pains) as
lungs. Rather within patient’s consumption and energy
verbalized by the
than developing normal range. expenditures and
patient
into healthy, reduced respiratory
Objective: normal lung reserve.
tissue, these
Restlessness abnormal cells Auscultate lungs for Consolidation and lack
Cyanosis continue air movement and of air movement on
Changes in dividing and abnormal breath operative side are
mentation form lumps or sounds. normal in the
masses of tissue pneumonectomy patient.
V/S taken as called tumors.
follows Tumors interfere Investigate May indicate increased
with the main restlessness and hypoxia or
T: 37.1 ˚C function of the changes in mentation complications such as
P: 101 lung, which is to or level of mediastinal shift in
R: 25 provide the consciousness. pneumonectomy patient
BP: 120/ 80 bloodstream when accompanied by
with oxygen to tachypnea, tachycardia,
be carried to the and tracheal deviation.
entire body. If a
tumor stays in Maintain patent Airway obstruction
one spot and airway by impedes ventilation,
demonstrates positioning, impairing gas exchange.
limited growth, suctioning, use of
it is generally airway adjuncts.
considered to be
benign. More Reposition Maximizes lung
dangerous, or frequently, placing expansion and drainage
malignant, patient in sitting of secretions.
tumors form positions and supine
when the cancer to side positions.
cells migrate to
other parts of Avoid positioning Positioning the patients
the body patient with a following lung surgery
through the pneumonectomy on with their “good lung
blood or lymph the operative side. down” maximizes
system. When a Favor the “good lung oxygenation by using
tumor down” position. gravity to enhance blood
successfully flow to the healthy lung,
spreads to other creating the best
parts of the body possible match between
and grows, ventilation and
invading and perfusion.
destroying other
healthy tissues, Encourage or assist Promotes maximal
it is said to have with deep breathing ventilation and
metastasized. exercises and pursed- oxygenation and reduces
This process lip breathing as or prevent atelectasis.
itself is called appropriate.
metastasis, and
the result is a
more serious
condition that is DEPENDENT:
very difficult to Administer Maximizes available
treat. Lung supplemental oxygen oxygen, especially while
cancer is called via nasal cannula, ventilation is reduced
"primary" if the partial rebreathing because pain.
cancer mask, or high
originates in the humidity face mask
lungs and as indicated.
"secondary" if it
originates Monitor graph of Decreasing Pao2 or
elsewhere in the ABGs, pulse increasing PaCO2 may
body but has oximetry readings. indicate need for
metastasized to ventilatory support.
the lungs. These
two types are
considered
different cancers
from diagnostic
and treatment
perspectives.
ASSESSMENT NURSING INFERENCE OBJECTIVES NURSING RATIONALE EVALUATION
DIAGNOSIS INTERVENTION
INDEPENDENT
Subjective: Acute pain Lung cancer i After 8 hours of -Provide comfort -Promotes relaxation and After 8 hours of
related to tissue s the most nursing measures such as redirects attention. Relieves nursing
“Nasakit nu
trauma common interventions, the frequent changes of discomfort and augments interventions, the
umanges nak” as
secondary to patient will be position, back rubs, and therapeutic effects of patient was able to
verbalized by the cause
patient.
CTT. able to report pain pillow support and etc. analgesia. report decreased pain
of cancer deat relief. relief as evidenced
Objective: h in men and -Schedule rest periods -Decreases fatigue and by:
women. Lung and provide quiet conserves energy,
-Restlessness cancer is the environment. enhancing coping abilities. Rated pain as: 5/10
carcinoma of
VS taken as -Assist with self-care -Prevents undue fatigue and
follows: the lungs char activities, breathing, arm incisional strain.
acterized by exercises and Encouragement and
-T: 36.8 uncontrolled ambulation. physical assistance and
growth of support may be needed for
-PR: 112
tissues of the some time before the patient
-RR: 24 lung. It usually is able or confident enough
to perform these activities
develops
-BP: 130/90 because of pain or fear of
within the wall pain.
-02Sat: 88% or epithelium
of the DEPENDENT
-Rated pain: 8/10 -Assist with patient- -Maintaining a constant
bronchial
controlled analgesia
tree. Its most drug level avoids cyclic
(PCA) or analgesia periods of pain, aids in
common through the epidural muscle healing, and
types are catheter. Administer improves respiratory
epidermoid intermittent analgesics function and emotional
routinely as indicated,
(squamous comfort and coping.
especially 45–60 min
cell) before respiratory
carcinoma, treatments, deep-
breathing or coughing
small cell (oat
exercises.
cell)
carcinoma,
adenocarcino
ma, and large
cell
(anaplastic)
carcinoma.
Although the
prognosis is
usually poor,
it varies with
the extent of
metastasis at
the time of
diagnosis and
the cell type
growth rate.
Lung cancer is
mostly
attributable to
the inhalation
of
carcinogenic
pollutants by
a susceptible
host. Any
smoker older
than 40,
especially if
the person
began to
smoke before
age 15, has
smoked a
whole pack or
more per day
for 20 years,
or works with
or near
asbestos.
Pollutants in
tobacco
smoke cause
progressive
lung cell
degeneration.
Lung cancer is
10 times more
common in
smokers than
in
nonsmokers.
Cancer risk is
determined
by the
number of
cigarettes
smoked daily,
the depth of
inhalation,
how early in
life smoking b
egan, and the
nicotine
content of
cigarettes.